08060158 CITY OF CUPERTINO /'� 'TIT"'
BUILDING DIVISION- PERMIT .k^dxl.QN l[H��'b� 3IATFU�RMAT7OIV
PERMIT NO.
BUILD)Nfi-APOR'kEVENS CREEK BLVD APT ORION FINANCIAL SERVICES 08060158
OWNLU 3A7MEE: J PERMIT ISSUE DAM
PROMETHEUS REAL ESTATE GROUP PO BOX 693 06/24/2008
NE:
SANITARY NO. CONTROL NO,
ARCHrfECT/ENGINEER: BUILDING PERMIT INFO
WASHER & DRYR BLDG EUCr PLUMB MECH
O O O O
O LICENSED CONTRACTOR'S DECLARATION '
w — Job Description
U e hereby affirm Wad 1 am Raved under and
Prole of Chapter 9(commencing
with Surce 7IX1a of aDivision J of me Business and Profcssiuv Code,and my license u
y
in full forte and ef(ea
j z Dah, Clue Coria
-Fp Dam SDEC
tractor
ARCHTIECrI'S DECLARATION
I understand my plus shell he used u public records
Die
a Licensed Professional
OWNER-BUILDER DECLARATION
I hereby alum that I am aempd from the Conu stem's License Law for the
❑O following rcumn.(Section 703 1.5,Business and Professons Code:Any city or county
5 m which requires a Permit in c mammal.alW.Impmw,dcmollm.or repair my gramme
_zy prior m is issuance.also mquims the Applicant for such permit to file a signed summon,
< that he islicenudpursuanttoWeprovisionsofdeContractor'slJecvclaw(Chapter9 Sq.Ft. Floor Area Valuation
Y1- (commencing with Section?000)x(Division 1 of me Business and Prefessioes Code)Or
e g-• that he u exempt therefrom and the basis farthe alleged aempmn.Any vWlatlan of
Section 7031.5 by my applicant fork permit subjects the applicant W.civil penalty of APN Number Occas Type
nut roam than It.hundred dollars(53001• Occupancy YP
❑I,as owner ofuie Property ter my employees with"gun theirsole compensation,
wilt dalmwok and Westinumisnor's
Licetloraw does
Pty th an..of
pro Ra who
code The ws tomos. ndwho law dao rod appy m rt owns of Required Inspections
property who builds o i meow uareon,and who does such work himself o ithrough Iter
own gnplaytes,provided grown mt U semau in not ear o ca maRercd ferrule.B,
however,the Wilding 01mPmwmmt V said within oro year ofi m roonf r dm owner
Wild=will naw the burden of proving that he aid trod turd or improv for purposi of
tile.).
0 1.u owner of the Property,am eadusiwly contracting with Raved ar uanan to
comedan the Mica(Sec.7044,Business and Professions Cade:)The Canuaemrs U.
cense law does am appy to an owner of property who builds or minnow theaemb and
who commas far such pmjecs wild a conuacter(O licensed pursuam to the Contractor's
Lim.Law.
❑Ismeacmptunim See ,B&PCrmthureawm
Owner Date
WORKER'S COMPENSATION DECLARATION
t hereby allirm under penalty of perjury one of dm following trelanuons:
1 haw and will mumu(.a Cenifimm ofConsent to self-Wun fo Worker&Comp
cation.es pmvidW fm by Sudors 3700 of the Labor Code.fm the performance of the
woh for which this permit is issued.
❑1 haw and will maintain Workers Compensation Insurance,as required by Section
3700 of the lather Code,fm the performance of the work for which this permit is issued
My Workeh Compevatian Insuranco arriu and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WOR)tERS'
COMPENSATION INSURANCE
(Thisaecam teed notthccompkted iliac Permit Is Enron hundred doBass(5100)
or less)
I madly Out in the pufomanee of este work for which this pennh is Wood.I shall mg
employ any Person in any manrtran as In became subject to me Wmkeri'Compaus uon
Lt.,of California.Due
A,U.t ...
NOTICE TO APPLICANT.If,*nor making this Certificate of Exemption,you chauW
became subject m the Wmaes Compensation pmdsians of the Labor Code you muss + -
.J 0 forthwith comply with such provisions or this permit shall be domed mokcd.
z CONSTRUCTION LENDING AGENCY
F 4 Ihachy affirm mat Wert is a construction ladingagcnry for the Performance of
W> the work for which this Permit is issued(Seo.3157,Civ.C.)
WM A Lenders Name
:D z Landers Add.
U Q I anify that I Mw mad this application and sate dull the show information is
IL cannot.e 1 agree to comply with all city and county animates and sum laws relating to
CU Wilding coramion.and hereby anthmda rtprescouuw ofthis city to cnurupnn the
CA above-menudgm pmperty forinspection purpowhich may
t„t 6. (We)agree to sire,indemnify and kap harmless the City of Cupertino against
CA inconscoluude,ofinecmtsand eapeveswhtch maythany way Acmuc agunst siid City
U z A consequence of the granting of this permit.
r•t
SOURCE
RE UNDERSTANDS AND WILL COMPLY WRH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
RAZA
SigSignatureof ApplieaDOU Date
HAZARDOUS MATERIALS
mamarlso lA5URE Type of Roof
Willytapplicantter fumm buildingoccupantstoreo handleh eanonsmateria
u defined io the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code.Sceuan 23s3zG>+
❑Yv ONO All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or fumm building Occupant use equipment or dcviw which If a roof is installed without first obtaining an inspection,I agree to remove
It havardou air conumivnu as defined by the Bay Ana Air Quuity Management all new materials for inspection.
D'grim7 P
❑Yes ❑Nu
I haw mW the hang dous ma crialsmquimmmu under Chapterd.95 of the Califor.
nu Health&SafetyCode,Stearns 25505,25533 aru25534.1 uMceand thatifdc Wilding
does not currently ham a tevv West it is my msponsibility In noufy tic osupam of the
requirements which mug ke met prior to issuance aft Conaria¢of Occupancy. Signature of Applicant Date
Owner or antharvad Agent Dam All roof coverings to be Class'%r{."or better
CITY OF CUPERTINO
• 8 ITEMS OF 40 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 36901021 . 105
DATE ISSUED. . . . . . . : 06/24/2008
RECEIPT # . . . . . . . . . : BS000005194
REFERENCE ID # . . . : 08060158
SITE ADDRESS . . . . . : 20350 STEVENS CREEK BLVD APT 1
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . . PROMETHEUS REAL ESTATE GROUP
ADDRESS . . . . . . . . . . : 1900 S NORFOLK ST STE 150
CITY/STATE/ZIP . . . : SAN MATEO, CA 94403
RECEIVED FROM . . . . : ORION FINANCIAL SVC
CONTRACTOR . . . . . . . : STEVE WHITESIDES LIC # 29564
COMPANY ORION FINANCIAL SERVICES
ADDRESS . . . . . . . . . . : PO BOX -693
CITY/STATE/ZIP . . . : ROSEVILLE, CA 95678
TELEPHONE . . . . . . . . : (916) 789-8484
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
IBSEISMICR VALUATION 3 , 900 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1ELECINSP HOUR 1 . 00 122 . 38 0 . 00 122 . 38 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1MECHINSP HOUR 1 . 00 122 . 38 0 . 00 122 . 38 0 . 00
1MPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1PLMBINSP HOURS 1 . 00 122 . 38 0 . 00 122 . 38 0 . 00
IPPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40. 79 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 530 . 80 0 . 00 530 . 80 0 . 00
•
CITY OF CUPERTINO BUILDING PERMIT APPLICATION
• E-Mail ORION(a)SUREWEST.NET
Jobsite Address: 20350 STEVENS CREEK BLVD Date: 6/23/08
APT 105
Owner's Name:PROMETHEUS REAL ESTATE GROUP
Phone No.:(408)253-7100
APN#: 369-01-02 i, / OS Project Valuation: $3900.00
Blg. Permit Information: Bldg. ■ Elec.■ Plumb.■ Mech.■
JOB DESCRIPTION
Washer and Dryer Retrofits; Kitchen and Bath cabinet and counter-
top upgrade. Ductless split system;HVAC Retrofit.
CONTRACTOR INFORMATION
• Company:ORION DEVELOPMENT . Phone:(916) 789-8484
Contact Name: STEVE WHITESIDES Fax:(916)789-1051
Address: P.O. BOX 693
City, State, and Zip:Roseville. CA 95678
State Contractors License: 747992 Exp. Date:9-30-2009
Worker's Comp.# : 238-0002445-07 Carrier:STATE FUND Exp. Date: 4-1-2009
Cupertino Business License#:
CREDIT CARD INFORMATION
Credit Card#
Name on Card: Orion Financial Services Inc.
Expiration Date: 01/10
Visa ❑ MasterCard ❑ Discover ❑ American Express ■
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